Portland State University PDXScholar International & Global Studies Faculty Publications and Presentations International & Global Studies 3-16-2011 Developing Countries, Vaccine Access and Influenza Outbreaks: Ethics and Global Health Governance When Facing a Pandemic Shawn Smallman Portland State University, [email protected] Follow this and additional works at: https://pdxscholar.library.pdx.edu/is_fac Part of the International and Area Studies Commons, and the Public Health Commons Let us know how access to this document benefits ou.y Citation Details Smallman, Shawn, "Developing Countries, Vaccine Access and Influenza Outbreaks: Ethics and Global Health Governance When Facing a Pandemic" (2011). International & Global Studies Faculty Publications and Presentations. 4. https://pdxscholar.library.pdx.edu/is_fac/4 This Conference Proceeding is brought to you for free and open access. It has been accepted for inclusion in International & Global Studies Faculty Publications and Presentations by an authorized administrator of PDXScholar. Please contact us if we can make this document more accessible: [email protected]. 1 Developing Countries, Vaccine Access and Influenza Outbreaks: Ethics and Global Health Governance When Facing a Pandemic Shawn Smallman Portland State University Paper presented at the annual meeting of the International Studies Association Annual Conference, "Global Governance: Political Authority in Transition", Le Centre Sheraton Montreal Hotel, Montreal, Quebec, Canada, Mar 16, 2011 2 The threat posed by influenza pandemics raises serious ethical issues, as well as questions of global health governance. In order to create pre-pandemic vaccines, global health authorities need access to virus from regional outbreaks. But because the countries where these outbreaks occur are unlikely to benefit from the vaccine, they are sometimes reluctant to share this seed stock, and may try to make proprietary arrangements with pharmaceutical companies, as briefly occurred in Indonesia. Although these arrangements may increase developing countries' access to vaccine, they hamper the global cooperation necessary to prepare for influenza outbreaks. Developing countries, in contrast, point to the United States' decision not to use adjuvants in influenza vaccines with the 2009 H1N1 outbreak, even though this is common in Europe, and it might make tens of millions of individual doses available for donation to developing countries. Similar issues bedevil preparation efforts, particularly concerning advance contracts for vaccines. This paper will examine a number of these challenges, and the global health policies needed to address them, based on Indonesia’s 2007 decision not to share viral samples with the WHO, as well as events during the 2009 H1N1 pandemic. Influenza Developing countries have long pointed to aspects of the World Trade Organization (in particular the Trade Related Aspects of 3 Intellectual Property agreement), which they feel unfairly hamper efforts to fight major epidemics. During the 1990s these disputes led to a major struggle around providing generic drugs to people living with HIV. This contest pitted the United States and pharmaceutical companies, on the one hand, against developing countries and non- governmental organizations, on the other. While this contest ended with a victory for the Global South, more recently, issues of global health equity have focused on influenza. The influenza virus is a very contagious agent that causes a respiratory disease. In the Northern hemisphere the flu season usually begins in October and peaks around February. The opposite is true in the Southern Hemisphere. For most people flu causes the rapid onset of exhaustion, aches, headache, coughing and heaviness in their chest. In most cases, with some time in bed and a little care, the flu quickly passes. But flu is a highly mutagenic virus, which sometimes undergoes major changes, in particular when a form adapted to birds enters into humans or other animals. In this case, the world can see a devastating pandemic. The worst pandemic of the twentieth century struck in 1918, when an avian form of the flu adapted to humans, and began to spread rapidly, perhaps from Haskell County, Kansas. By the time that the disease had run its course perhaps 40 million people had died, from the hills of Northern India, the country most devastated by the disease, 4 to the trenches of Western Europe during World War One.1 Many famous people, such as Woodrow Wilson, may have been infected by the disease, which also killed William Osler, the outstanding physician of the age.2 As Alfred Crosby and Arno Karlen have argued, one of the most unusual aspects of the pandemic is that it has been largely forgotten. 3 Significant influenza pandemics also swept the globe in 1957 and 1968, although neither caused the mortality of the 1918 outbreak. In some respects, little has changed in the intervening decades. We do have some treatments now for the flu. There are currently four drugs used to treat influenza, which can only be obtained in most developing countries with a prescription. All must be taken within a short period of developing symptoms, and none cures the illness. Instead, they shorten the course of the disease and alleviate suffering. Vaccines are also available, but they currently represent an imperfect means to address this threat. The flu virus mutates rapidly and there are many different strains, each characterized by different proteins in their outer 1 Mike Davis. The monster at our door: The global threat of avian flu. (New York: The New Press, 2005), 26, 32. 2 Barry, J.M. The great influenza: The epic story of the deadliest plague in history. (New York: Penguin, 2005), 387. 3 Alfred Crosby, America’s forgotten pandemic: The influenza of 1918. (New York: Cambridge University Press, 1990); Arno Karlen. Plague’s progress: A social history of man and disease. (London: Victor Gollancz. 1995), 145. 5 shell. Every year scientists scour the planet looking for different forms of the virus. They then have to guess which forms will likely dominate epidemics in the coming winter (for each hemisphere). They come to a consensus on three different forms. It then takes months to grow the virus in chicken eggs. One challenge is that vaccine designers sometimes guess incorrectly, and a strain of virus will circulate widely which is not covered by that year’s vaccine. Another risk is that a novel form will appear for which the vaccine developers are completely unprepared. The current vaccine technology has other limitations, not the least of which is that entails the use of millions of chicken eggs, which are not only time consuming, but also could be difficult to obtain if a bird flu pandemic wiped out chicken farms. Contamination can also be a challenge, as proved the case in October 2004, when a plant owned by Chiron in the United Kingdom produced a vaccine contaminated by a bacteria. This one failure meant that the U.S. health system lost tens of millions of expected doses of vaccine.4 The U.S. media asked how the country could deal with pandemic flu, if it could not guarantee a vaccine supply in a normal year? For this reason, as well as to shorten the time entailed for vaccine preparation, there is currently a major effort to create new vaccine technologies, which would no longer rely on old egg-based approaches to production. Recent events have made 4 Davis, 140-144. 6 this a high priority for the United States government, as well as other global health actors. Initially, global health officials focused on the threat from bird flu. In 1997, an outbreak of bird flu in Hong Kong sickened eighteen people and killed six. The government killed more than a million chickens in a few days, which stamped out the outbreak.5 But this was not the only appearance of bird flu. In February 2004, an outbreak of a different strain of bird flu in the Fraser Valley of British Columbia caused the Canadian Food Inspection Agency to order the destruction of nearly twenty million chickens. In 2003 and 2004 bird flu again appeared in South East Asia, particularly in Vietnam, and it has since spread to countries as geographically distant as Turkey and Indonesia. Then in 2009 a new form of influenza, novel H1N1 (the so-called swine flu) emerged in Mexico. In the end, the 2009 pandemic did not resemble that of 1918. This was fortunate because in the northern hemisphere most people did not have access to the vaccine until after the epidemic had peaked. Even before the 2009 pandemic, efforts to fight the flu raised key moral questions. European and North American governments collectively spent billions of dollars stockpiling medications, testing vaccines, and encouraging basic research on the flu. At the same time, developing nations struggling to contain bird flu found comparatively 5 Davis, 45-54. 7 little aid forthcoming for tasks such as culling infected flocks. With the emergence of H1N1, developed countries were able to activate pre- existing contracts with major vaccine manufacturers, which gave their countries first access to the vaccines produced. The manufacturers would not take orders from poorer but more populous countries, because they did not have the capacity. This inequality threatened international efforts to contain flu pandemics. Indonesia Even before the emergence of novel H1N1, developing nations proved reluctant to collaborate with First World nations to develop possible vaccines, because they knew they were unlikely to benefit from this research in the event of an outbreak. In some cases, developing countries may have sought access to vaccines in the event of an outbreak, by making deals with companies that could provide vaccine in exchange for access to emerging viral strains. Indonesia, for example, did not want to share strains of the bird flu collected from fatalities because the country unless it was guaranteed access to any vaccine developed from this resource: In January, frustrated that an Indonesian strain of the virus had been used to make a vaccine that most Indonesians would not be able to afford, the country stopped cooperating with the W.H.O.